New Patient Intake Form

New Patient Intake Form
Please complete this form to help us provide you with the best care. Your information is kept confidential.
Dear Patient, We are so glad you have chosen to begin your mental wellness journey with us. At Catalyst Integration for Health we are commited to providing compassionate, evidence-based care tailored to your unique needs. We treat ages 10 and up. Whether you are seeking support for emotional well-being, medication management, or personal growth, our goal is to create a safe and supportive space for healing and transformation. We do reserve the right to perform drug screening at random. Initial consultation $200.00, follow-up visits $150.00 and drug screening is $40.00. For all patients there will be a $50.00 fee if you do not show up for your visit or do not cancel your visit 24 hours before your scheduled appointment time. If you are 10 minutes late for your visit, even if you call on the way in, it will be considered a no show, and you will need to reschedule your visit and will be charged $50.00 no show fee. If you are late and the schedule allows, we will try to fit you in, however this is not a guarantee as we have other patients scheduled and may not be able to accommodate you. Even if we are able to fit you in you will be charged a late fee of $50.00. This includes in-person and telehealth appointments. We look forward to working together to help you elevate and emerge into the best version of yourself. If you have any questions or need support, don't hesitate to reach out. You can call us at 916-850-2299 Warmly, Catalyst Integration for Health
Recipient's Rights Notification
Your rights as a patient
Complaints. We will investigate your complaints.

Suggestions. You are invited to suggest changes in any aspect of the services we provide

Civil rights. Your civil rights are protected by federal and state laws

Cultural/spritual/gender issues. You may request services from someone with training or experience from a specific cultural, spiritual, or gender orientation

Treatment. You have the right to take part in formulation your treatment plan

Denial of services. You may refuse services offered to you and be informed of any potential consequences.

Record restrictions. You may request restrictions on the use of your protected health information; however, we are not required to agree with the request

Availability of records. You have the right to obtain a copy and/or inspect your protected health information; however, we are not required to agree with the request

Amendment of records. You have the right to request an amendment in your records; however, this request could be denied. If denied, your request will be kept in the records

Medical/legal advice. You may discuss your treatment with your doctor or attorney

Disclosures. You have the right to receive an accounting of disclosures of your protected health information that you have not authorized.

Medications used in your treatment. We will provide you with information descibing any potential risks of medications prescribed at our facility

Cost of services. We will inform you of the cost

Termination of services. You will be informed as to what behaviors or violations could or did lead to termination of services at our clinic

Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will be used.

Policy changes. You will be notified of any policy changes as they arise
We dedicate ourselves to serving the best interes of each client

We wil not discriminate between clients or professionals based on age, race, creed, ability, preferences, orother personal concerns

We maintain an objective and professional relationship with each patient

We respect the rights and views of other mental health professionals

We will appropriately end services or refer clients to other programs when appropriate

We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the
purpose of self improvement.

We will continually attain further education and training.

We respect various institutional and managerial policies but will help to improve such policies if the best interest of the client is served

You are responsible for your financial obligations to the clinic as outlines in the Fee Schedule

You are responsible to treat staff and fellow patients in a respectful, cordal manner in which their rights are not violated
You are responsible to provide accurate information about yourself
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Gender Identity

Pronouns
Marital Status
Employer or School Name
Employer or School Address
Employer or School Phone Number
Format: (000) 000-0000.
Please enter a valid phone number.
Occupation or Position
Who referred you to our clinic?
Primary Care Physician Name
Primary Care Physician Phone Number
Format: (000) 000-0000.
Please enter a valid phone number.
Psychiatric Provider Name (if applicable)
Therapist Name (if applicable)
Therapist Phone Number (if applicable)
Format: (000) 000-0000.

Please enter a valid phone number.
Emergency Contact 1: Full Name
Emergency Contact 1: Relationship to Patient
Emergency Contact 1: Phone Number
Format: (000) 000-0000.
Please enter a valid phone number.
Primary Insurance Carrier
Primary Insurance ID #
Primary Insurance Group #
Secondary Insurance Carrier (if applicable)
Secondary Insurance ID #
Secondary Insurance Group #
Signature
Date Signed

MonthDayYear

Have you been hospitalized in the last 5 years? If yes, please provide details.
Have you had problems with anesthesia? If yes, please describe.
Do you have allergies to any medications? Please list medications and reactions.
Do you use illegal/recreational drugs? Please provide details.

Do you consume alcohol? How much? How often?
Do you use tobacco or vaped tobacco? Please describe.
Have you had any accidents or injuries in the last year? Please describe.
Have you experienced significant weight changes in the last year? Please describe.
Do you have sleep problems? Please describe.

Rows	Self	Mother	Father	Siblings
Anxiety
Depression
PTSD/Trauma
Psychosis
Schizophrenia
Suicidality
Bipolar Disorder
Personality Disorder
Epilepsy
High Blood Pressure
Chronic Pain
Migraines
Aneurysm
Substance/Alcohol Abuse
Kidney Disease
Liver Disease
Heart Disease
Closed Angle Glaucoma

Rows	Not at all	Several days	More than half the days	Nearly every day
Feeling down, depressed, irritable, or hopeless?
Little interest or pleasure in doing things?
Trouble falling asleep, staying asleep, or sleeping too much?
Poor appetite, weight loss, or overeating?
Feeling tired, or having little energy?
Feeling bad about yourself or feeling that you are a failure or that you have let yourself or your family down?
Trouble concentrating on things like school, work, reading, or watching TV?
Moving or speaking so slowly that other people or the opposite-being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead or of hurting yourself in some way?

Rows	Yes	No
In the past few weeks have you wished you were dead?
In the past few weeks have you felt that you or your family would be better off if you were dead?
In the past week have you been having thoughts of killing yourself?

New Patient Intake Form

Recipient's Rights Notification